One York Emergency Relief Fund Student Application

Empl ID

First Name

Last Name

Yorkmail

Email Address

Preferred Address

(If different from CUNYfirst) Home Number, City, State, and Zip

Number of Credits

Graduate Student

Yes

Phone Number

Preferred Contact Method

Email

Phone

Enter Application Letter

Please explain your critical financial hardship (no more than 2000 characters). Supporting documentation is required for approval and awards are subject to the availability of funds on a first-come, first-serve basis.

Amount requested

$2,000 Max (2000)

COVID-19 Related Catastrophic Event you have encountered

Death in the household

Uninsured medical expenses caused by severe illness or accident

Uninsured losses caused by fire, crime, flood income, or other disasters

Unusual uninsured expenses for the care of a sick family member

Job loss of a family household member

Primary income earner

Other

You must provide proof that you have experienced a COVID-19 related emergency. Acceptable forms of documentation are: Certified Death Certificate, Obituary, Medical Bills, Insurance Claims, Police Report, Expense Receipts, Proof of Unemployment, Foreclosure or Eviction Notices.

Catastrophic Event	Documents Needed
Death in the household	Certified Death Certificate, Obituary Medical Bill(s),
Uninsured medical expenses caused by severe illness or accident	Certification of Medical Condition
Uninsured losses caused by fire, crime, flood income, or other disasters	Insurance claims, Police reports
Unusual uninsured expenses for the care of a sick family member	Expense Receipts
Job loss of a family household member	Proof of Unemployment, Foreclosure, or Eviction Notices
Tuition	Proof of overdue tuition bill due to financial hardship
Other	Any supporting documentation that substantiates your request

I have read and understand

I Agree

I Disagree

I have read and understand the provisions of the One York Emergency Relief Fund Applicant Agreement and know that I may apply only once to this fund. I understand that completion of this form is not a guarantee of approval.

I hereby authorize

I Agree

I Disagree

I hereby authorize the appropriate individuals to review my student records and disseminate information relating to my time at York College to a committee of faculty, students, and administrators. I understand the information will be handled privately, anonymously, and will not be shared. I accept the final decision of the committee.